Rose City Nursing and Rehab at Lancaster

In the surveyor’s words

From the most serious findings on record at Rose City Nursing and Rehab at Lancaster, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 20, 2026

  Based on observations, facility record review, as well as resident and staff interviews, it was determined the facility failed to ensure resident smoking materials were stored securely and monitored for four residents (Residents 18, 74, 92, 93) on two units, posing a risk for fire, resulting in immediate jeopardy to the residents (first and third floor units).Findings include:Interview with the Nursing Home Administrator (NHA) during the entrance conference on May 17, 2026, at approximately 10:30 a.m., revealed the facility is a non-smoking facility and have no smoking policy. Further interview with the NHA revealed there were four residents in the building who were permitted to smoke if they had a physician's order allowing them to leave the facility unaccompanied. […]

• Immediate jeopardy, isolatedF656Dec 1, 2023

  Based on clinical record, facility documentation, and staff interviews, it was determined that the facility failed to ensure and implement a comprehensive care plan for residents CL1 and R4 with history of seeking and aggressive behaviors which resulted in Resident CL1 ingesting a sandwich subsequently choking and expiring. Resident R4 exhibited physical aggressive behaviors which resulted in an involuntary psychiatric hospitalization . This failure placed residents in Immediate Jeopardy for two of two residents identified as being at risk. […]

• Immediate jeopardy, isolatedF689Dec 1, 2023

  Based on facility documentation, clinical record review and staff interviews it was determined the facility failed to implement appropriate monitoring, supervision, and safety measures to prevent Resident CL1, with known seeking behaviors and receiving a specialty diet, from obtaining a sandwich from an unsupervised cart. Resident CL1 ingested the sandwich which caused resident to choke on the food and expire. This failure placed residents at the facility in an Immediate Jeopardy situation for one of one resident identified as being at risk. […]

• Immediate jeopardy, isolatedF678Jan 8, 2021

  Based on a review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for one of five residents reviewed (Resident R1), creating a situation in which the resident was placed in Immediate Jeopardy related to failing to perform cardiopulmonary resuscitation. […]

• Actual harm, isolatedF689Mar 3, 2021

  Based on observations of resident care and services, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to provide an adaptive device to prevent accidental spilling of a beverage which resulted in a burn injury causing harm to one of 32 residents reviewed (Resident R59). Findings include: Review of the facility policy titled, Assistive Devices and Equipment, revised on July 2017, states, Staff and volunteers will be trained and will demonstrate competency on the use of devices and equipment prior to assisting or supervising residents. […]